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Effectiveness of undergraduate medical students training on LGBTQIA + people health: a systematic review and meta-analysis

BMC Medical Education volume 24, Article number: 63 (2024) Cite this article

Abstract

Background

Adequacy of learning models and their ability to engage students and match session’s objectives are critical factors in achieving the desired outcome. In this systematic review and meta-analysis, we assess the methodological approach, content, and effectiveness of training initiatives addressing medical students’ knowledge, attitudes, confidence and discrimination perception towards LGBTQIA + people.

Method

PubMed, Web of Science, Medline and Scopus were searched to identify published studies, from 2013 to 2023, on effectiveness of training initiatives addressing medical students’ knowledge, attitudes, confidence and discrimination perception towards LGBTQIA + people. The risk of bias of the selected studies was assessed by the Medical Education Research Study Quality Instrument. Overall effect sizes were calculated using a Mantel–Haenszel method, fixed effect meta-analyses.

Results

A total of 22 studies were included, representing 2,164 medical students. The interventions were highly diverse and included seminars, lectures, videos, real-case discussions, roleplay, and group discussions with people from the LGBTQIA + community. After the interventions, there was a significant improvement in self-confidence and comfort interacting with patients and in the understanding of the unique and specific health concerns experienced by LGBTQIA + patients.

Conclusion

Our findings indicated that the outcomes of interventions training actions for medical students that promote knowledge and equity regarding LGBTQIA + people, regardless of their scope, methodology and duration, result in a considerable increase in students’ self-confidence and comfort interacting with LGBTQIA + patients, highlight the need for more actions and programs in this area promoting a more inclusive society and greater equity.

Peer Review reports

Background

In recent years, several European and US-based organisations have released guidelines with the goal of reducing disparities and promoting health equity, particularly those involving the LGBTQIA + population (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual people. The plus sign represents people with diverse sexual orientation, gender identity, gender expression and sex characteristics who identify using other terms) [1]. Several studies showed that Sexual and Gender Minority (SGM) individuals have inferior health status, higher mortality and morbidity rates, and less access to health care [2,3,4,5,6,7,8,9,10,11]. This complex scenario derived from an intersectional framework penalizing LGBTQIA + individuals.

In a 2011 [12], the Joint Commission International outlined the necessity for healthcare organizations and their professionals to deliver high-quality out health care services while respecting the diversity of their patients in a patient-centred practice. To support trans-inclusive college health programs, the American College Health Association produced guidelines that provide detailed instructions on how to foster greater tolerance, inclusiveness, and more equitable health care, emphasizing the importance of developing strategies to close the gap [13, 14].

Several medical schools have attempted to take measures to reduce the gap, create a more equal health and empowerment SGM community, recognizing the fact that we live and are educated in a heteronormative society which is reflected in medical education. Integration of LGBTQIA + health training can significantly reduce health disparities and promote health equity [15–18].

The role of medical education in shaping the next generation of healthcare providers is critical. It is therefore essential that medical students receive comprehensive training that prepares them to provide effective medical care to all patients [19, 20].

In this context, there are many different interventions that are used in medical education, including traditional classroom instruction, hands-on clinical training, simulation-based learning, and the use of digital technology such as virtual reality [21,22,23]. Each of these interventions has unique strengths and weaknesses, and the choice of intervention will depend on the learning objectives, availability of resources, and the preferences of the students and faculty.

Since adult learning theories recognize that students have unique experiences, needs, and motivations that influence how they acquire new knowledge and skills, the use of lectures by itself is not sufficient to ensure that students comprehend and specially, retain information [24,25,26]. Therefore, other teaching methods that promote active learning and facilitate the development of critical thinking skills should be considered, including problem-based learning, team-based learning, and case-based learning [27,28,29].

Another critical issue is the inclusion of LGBTQIA + people in medical education centred in SGM health. The inclusion of individual histories and experiences in medical education is of paramount importance as it provides invaluable learning opportunities for healthcare professionals. Patients are the central focus of healthcare, and their experiences and perspectives can provide students with a unique insight into the challenges and complexities of healthcare delivery [30,31,32,33].

In this context, involving LGBTQIA + people in medical education initiatives helps to bridge the gap between theoretical knowledge and clinical practice, allowing that students can apply the knowledge and skills in real-life situations promoting a better understanding of the impact of their actions on patients’ health outcomes [34, 35]. It also promotes a more effective communication, empathy, and understanding of the patient’s preferences, values, and beliefs, and thus encourages a patient-centred approach in medical education. Patients can provide feedback on their experiences, which can be used to identify areas for improvement in healthcare delivery and curriculum design.

Finally, involving LGBTQIA + people in medical education can contribute to reducing stigma and discrimination, helping students to challenge their assumptions and biases and develop an open-minded and respectful approach to patient care [30, 36].

In this systematic review and meta-analysis, we assess the methodological approach, content, and effectiveness of training initiatives addressing medical students’ knowledge, attitudes, confidence and discrimination perception towards LGBTQIA + people.

Methods

Study design and inclusion criteria

The PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [37] and the recommendations of the Cochrane Handbook were followed [38]. The included studies should meet the following criteria:

Population - medical undergraduate students.

Intervention - lecture, workshops, case studies, role play or discussion groups about SGM health.

Condition of interest - knowledge, attitudes, communication, discrimination and/or confidence regarding LGBTQIA + people health;

Outcomes - knowledge, attitudes, confidence, communication skill and/or discrimination outcomes measured by objective assessment instruments (including scales but also self-reported surveys, self-assessment of knowledge and attitudes).

Literature sources and searches

The Web of Science, Medline, PubMed, and Scopus were searched for the following terms: (LGBT* OR gender minority OR sexual minority OR gay OR transgender OR gender identity) AND (medical OR medic*) AND (student* OR undergraduate* OR universit*) AND (train* OR action OR formation OR workshop OR class OR education) AND (knowledge OR communication OR discrimination OR confidence), limited to the last 10 years. The search was conducted on March 17th, 2023.

Screening and data extraction

An initial screening of titles was performed by (AM) based on the inclusion criteria. Duplicates and studies that were clearly not related to the aims of this review were excluded. The abstracts were then screened independently by two reviewers (AM and CF) using the above criteria. The relevant studies and those for which the abstract raised doubts were independently assessed by the two reviewers in full text. All disagreements were resolved by consensus.

Information on study characteristics, design, intervention, participants, and outcomes was extracted from each of the studies. This data included authors, study date, university, sample size, medical year of students, study design, and interventions and outcomes. Zotero [39] was also used to obtain some publication data, such as titles, editors, URLs, digital object identifiers, page numbers, issue numbers, and volume numbers. The percentage of students who met the training program’s objectives was considered, together with the mean score change and standard deviations of the pre- and post-intervention.

Risk of bias assessment

The quality of the studies was assessed by two reviewers, using the Medical Education Research Study Quality Instrument (MERSQI) [40, 41]. The MERSQI was developed to appraise methodological quality in medical education research and is suitable, reliable and simple to use. The comparison with the Newcastle-Ottawa Scale-Education (NOS-E) showed that both are useful, reliable, tools for appraising methodological quality of medical education researchco [40]. The MERSQI is composed of 10 items reflecting 6 domains of research quality (study design, sampling, type of data, validity, data analysis, outcomes).

Meta-analysis

RevMan 5.4.1 (The Cochrane Collaboration) software was used. Likewise, although some studies assessed several different outcomes, in this meta-analysis, we included only the most frequent and homogeneous outcomes, namely students’ self-confidence and comfort interacting with LGBTQIA + patients and the understanding of the unique and specific concerns experienced in medicine by LGBTQIA + patients. The Mantel–Haenszel method was used. The standard mean difference (SMD) with 95% confidence intervals (CIs) was applied for the overall effect of group comparisons for continuous outcomes. The pooled odds ratio (OR) with 95% confidence interval (95% CI) was calculated to evaluate the percentage of students who met the intervention learning objectives. The statistical heterogeneity was calculated using the I2 statistic [42]. We set the significance level at 0.05 for pooled estimation results and built forest plots for each outcome.

Results

From the 5,292 papers identified, 1,860 duplicates were removed manually, 3,379 articles were excluded based on title and abstract screening. Fifty-three full articles were then screened. However, 1 of them could not be accessed in the full text, and 30 articles were excluded against the inclusion criteria. Finally, 22 articles [43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64] were included for this systematic review (Figs. 1) and 11 were included in the meta-analysis [43, 44, 52, 53, 55, 59, 60, 60,61,62,63, 65].

Fig. 1
figure 1

Study inclusion flowchart

Full size image

Synthesis of included articles

The studies evaluated 2,164 medical students, ranging from 1st to the final year, and were conducted in the United States, the United Kingdom, Ireland, Switzerland, the Republic of Korea, and Australia. The interventions were highly diverse, ranging from 1 to more than 10 h in several weeks and included seminars, lectures, videos, real-case discussions, roleplay, and group discussions with individuals from the LGBTQIA + community. Tables 1 and 2 summarize the studies’ characteristics, interventions, and results.

Table 1 Studies characteristics
Full size table
Table 2 Studies results and conclusions
Full size table

Studies have shown that interventions, whether brief and simple, enhance students’ self-confidence in their knowledge, attitude, and capacity for interfacing with LGBTQIA + people.

The results concerning the level of knowledge are more heterogeneous. While some studies showed a significant increase in students’ knowledge regarding language comprehension, the use of suitable and inclusive language, and the ability to identify specific health conditions, other showed no significant changes in the level of knowledge after the interventions.

Both students and teachers valued the participation of LGBTQIA + community members in the discussion forums, roleplay scenarios, or as moderators.

Quality: risk of bias in individual studies

Tables 2 and 3 displays the studies’ methodological quality scores. The mean consensus MERSQI score was 10.2 out of a maximum of 18. None of the articles attained a score of more than 12 points. However, 18 (78.3%) scored over 10 points, indicating good methodological quality, considering that our analysis includes only single centre nonrandomized studies.

Table 3 Medical Education Research Study Quality Instrument Results (n = 22)
Full size table

Meta-analysis

The meta-analysis showed that after the interventions, there was a significant improvement in the students’ self-confidence and comfort interacting with LGBTQIA + patients. The mean difference across the 7 studies on a 5-point Likert scale pre-post test scores was 0.37 [0.26–0.48], p 0.00001, I2 = 89%. Four studies evaluated the percentage of students who answered that their confidence and comfort interacting with LGBTQIA + patients improved after the intervention. The results showed a significant improvement of 4.97 [3.61–6.84], p < 0.00001, I2 = 0% (Fig. 2). A significant improvement in understanding of the unique and specific concerns experienced in medicine by LGBTQIA + patients was found after evaluating five studies (six comparisons), with a mean difference on a 5-point Likert scale pre-post test scores of 1.01 [0.87–1.15], p 0.00001, I2 = 77% (Fig. 3).

Fig. 2
figure 2

Students’ self-confidence and comfort interacting with LGBTQIA + patients. Mean changes in 5 points Likert scales. Notes: CI - Confidence interval; M-H - Mantel–Haenszel method; SGM – Sexual and gender minority people; SD - Standard deviation; TG - Transgender people

Full size image
Fig. 3
figure 3

Understanding of the unique and specific concerns experienced in medicine by LGBTQIA + patients. Mean changes in 5 points Likert scales. Notes: CI - Confidence interval; M-H - Mantel–Haenszel method; SGM – Sexual and gender minority people; SD - Standard deviation; TG - Transgender people

Full size image

Discussion

In this review, we analyse the results of 22 studies, including 2164 medical students, regarding the effectiveness of interventions designed to promote knowledge and improve medical students’ confidence and comfort regarding level LGBTQIA + people. Overall, the studies had good methodological quality, with appropriate designs, scales, and statistical analyses, ensuring good internal validity. This is crucial to support the significance of our meta-analysis results.

The first aspect to be highlighted is the diversity of the interventions, both in terms of form, content, and duration. Overall, it was found that the level of knowledge about specific aspects of LGBTQIA + people health did not increase as expected after the interventions, but there was a significant increase in the students’ self-reported confidence and comfort. The analysis also shows that the interventions included moderators who were members of the LGBTQIA + community had very good results, emphasizing the importance of emotional and personal bonding beyond the simple transmission of theoretical content.

In recent years, the number of studies addressing the effectiveness of educational activities directed to medical students about LGBTQIA + people health specificities has significantly increased, translating the gap and the perceived need [30, 66].

This is probably the reflex of several statements and reports published by medical schools in the last decade. In 2014, the Association of American Medical Colleges published a document, entitled Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT [67], which is based on the assumption that medical students have little or no information about SGM population in their formal academic curriculum, constituting a huge barrier to the future relationship with SGM people, and making urgent the need to incorporate this subject, in the curricula.

In our view, the incorporation of issues related to the health of LGBTQIA + people should be implemented by including LGBTQIA + people health specific themes immersivity in the medical curricula. The transversal incorporation of the theme, not focusing on one or the other disease, avoids the stigma associated to some pathologies, of which HIV infection is a paradigmatic example [68, 69].

In medical education concerning the health of LGBT people, it is crucial to emphasise that there are unique aspects, but also that many of the issues are transversal to all of society. In many conditions the impact is different, not so much by biological and clinical characteristics, but mainly by access to health care and social involvement, which determine asymmetries in health equity.

While the formal inclusion of the theme is critical, it does not obviate the implementation of more focused actions in specific themes, allowing the important direct contact with LGBTQIA + people and with life stories told in the first person, which is associated with a greater bond on the part of students, fundamental to increase their confidence and comfort in the clinical approach.

Several strategies can be utilized to better engage medical students in learning about LGBTQIA + people health and reducing health disparities in this community. First, it is vital to create a safe and inclusive learning environment that encourages open and respectful dialogue. This can be achieved by providing opportunities for students to share their own experiences and perspectives, as well as by inviting LGBTQIA + individuals to moderate the session and share experiences. Second, case studies, interactive simulations, and role-playing activities can be integrated to improve the understanding of the complex social and structural factors that affect LGBTQIA + people health. And, finally, providing ongoing support and mentorship to medical students can help ensure their continued engagement in addressing LGBTQIA + health disparities.

Strengths and limitations

This systematic review includes more than 2000 students and gives an overview about the kind of interventions that have been done in the last decade regarding LGBTQIA + health in undergraduate medical education. One of the most important conclusions is that, above increasing the level of knowledge, the interventions carried out appear to improve students’ confidence and comfort in communicating with SGM people. This will improve the doctor-patient relationship, crucial for a true equity and inclusion.

In addition, our study has some limitations. First, the heterogeneity of interventions and outcomes evaluation methodology.

Second, the absence of control groups, which means that interventions can only be evaluated by a pre-post-test methodology, and as such biased by participants’ expectations. Third, the lack of long-term evaluation. Most studies only evaluate the outcome immediately after the intervention, giving no information on how long the outcome lasts over time.

Conclusion

Our findings indicated that the outcomes of interventions training actions for medical students that promote knowledge and equity regarding LGBTQIA + people, regardless of their scope, methodology and duration, result in a considerable increase in students’ self-confidence and comfort interacting with LGBTQIA + patients, highlight the need for more actions and programs in this area promoting a more inclusive society and greater equity.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

CI:

Confidence intervals (

LGBTQIA+:

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual people. The plus sign represents people with diverse sexual orientation, gender identity, gender expression and sex characteristics who identify using other terms

MERSQI:

Medical Education Research Study Quality Instrument

OR:

Odds ratio

SGM:

Sexual and Gender Minority

SMD:

Standard mean difference

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Acknowledgements

Camara Municipal de Loulé.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This study was supported by Camara Municipal de Loulé for publication costs.

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Authors and Affiliations

  1. Faculty of Medicine and Biomedical Sciences (FMCB), University of Algarve, Edifício 2 – Ala Norte Campus de Gambelas, Faro, 8005-139, Portugal

    Ana Macedo

  2. ABC Clinical Reseach Center, Algarve Biomedical Center (ABC), Edifício 2 – Ala Norte Campus de Gambelas, Faro, 8005-139, Portugal

    Ana Macedo

  3. National Statistical institute of Portugal, Lisboa, Portugal

    Maria Aurindo

  4. Faculty of Medicine, University of Porto, Porto, Portugal

    Cláudia Febra

Authors
  1. Ana Macedo
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  2. Maria Aurindo
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  3. Cláudia Febra
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Contributions

All authors contributed to the conception and design of the study. Data extraction was performed by A.M. and was sup-ported by C.F. Analyses were conducted by A.M. The first draft of the article was written by A.M.A.M. C.F. MJ.A. critically reviewed and revised multiple drafts of the article. All authors approved the final article before submission.

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Correspondence to Ana Macedo.

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Macedo, A., Aurindo, M. & Febra, C. Effectiveness of undergraduate medical students training on LGBTQIA + people health: a systematic review and meta-analysis. BMC Med Educ 24, 63 (2024). https://doi.org/10.1186/s12909-024-05041-w

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Keywords

BMC Medical Education

ISSN: 1472-6920

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